Traumatic Atlanto-occipital Dislocation: Analysis of 15 Survival Cases With Emphasis on Associated Upper Cervical Spine Injuries.

STUDY DESIGN: Retrospective case analyses. OBJECTIVE: The aim of this study was to investigate the incidence and characteristics of associated upper cervical spine injuries in 15 survival cases of traumatic atlanto-occipital dislocation (AOD). SUMMARY OF BACKGROUND DATA: Traumatic AOD is a rare and generally fatal injury. Information regarding associated upper cervical spine injuries that may affect treatment methods, outcomes, and prognosis is limited. METHODS: Fifteen patients (11 patients with posterior-type AOD and four patients with vertical-type AOD) who survived traumatic AOD were included in this study. Plain radiographs, computed tomography, magnetic resonance imaging, and medical records were reviewed. The incidence and characteristics of associated upper and lower cervical spine and thoracolumbar spine injuries and brain injuries were evaluated. RESULTS: Thirteen patients with traumatic AOD (11 patients with posterior-type AOD and two patients with vertical-type AOD) showed associated upper cervical spine injuries; the overall incidence was 87% (100% in posterior-type AOD and 50% in vertical-type AOD). In posterior-type AOD, eight (72.7%) patients had C1 fractures (four patients had three-part fracture, three patients had two-part fracture, and one patient had four-part fracture), four (36.4%) patients had C1 lateral mass fractures, two (18.2%) patients had transverse atlantal ligament injuries. In vertical-type AOD, two (50%) patients had C1-C2 vertical subluxation with C1 anterior arch horizontal and sagittal split fractures. In posterior-type AOD, two (18%) patients had lower cervical spine injuries and one (9%) patient had brain injury. In vertical-type AOD, one (25%) patient had thoracic spine injury, and three (75%) patients had brain injuries additionally. CONCLUSION: Survival cases with traumatic AOD showed a high incidence of associated upper cervical spine injuries and brain injuries. High index of suspicion and careful radiologic examination are needed to investigate the presence of associated upper cervical spine injuries and brain injuries in traumatic AOD, which affects treatment, outcome, and prognosis. LEVEL OF EVIDENCE: 4.

Radiologic criteria to predict injury of the transverse atlantal ligament in unilateral sagittal split fractures of the C1 lateral mass.

Unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM) has been recently recognized as a rare variant of C1 atlas fracture. To date, there has been no study to investigate whether radiologic criteria can be applied to determine the presence or absence of transverse atlantal ligament (TAL) injury in USSF of the C1 LM.Twenty six consecutive cases of USSF of the C1 LM were included in this study. According to Dickman classification, 16 cases were TAL injury, and 10 cases were TAL intact. Radiologic parameters were measured and compared between the 2 groups.Total LM displacement (LMD) of the 2 sides (5.9 ±â€Š2.0 mm vs 1.2 ±â€Š2.0 mm), unilateral LMD of the fracture side (4.3 ±â€Š1.2 mm vs 1.0 ±â€Š1.1 mm), atlanto-dental interval (ADI) (2.0 ±â€Š0.9 mm vs 1.5 ±â€Š0.4 mm), and fracture gap (6.9 ±â€Š2.7 mm vs 2.1 ±â€Š1.1 mm) were statistically higher in the TAL injury group than the TAL intact group. However, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were not different between the 2 groups. Total LMD and unilateral LMD positively correlated with ADI and fracture gap. The incidence of fracture gap larger than 7 mm was statistically higher in the TAL injury group than the TAL intact group (81% vs 30%).In conclusion, total LMD > 5.9 mm or unilateral LMD > 4.3 mm suggests the presence of TAL injury in USSF of the C1 LM. The possibility of diagnostic error for TAL injury can be further reduced in USSF of the C1 LM by considering the fracture gap larger than 7 mm.

Clinical and radiological outcomes of conservative treatment for unilateral sagittal split fractures of C1 lateral mass.

OBJECTIVE: The aim of this study was to assess the effect of transverse atlantal ligament (TAL) integrity on clinical and radiological outcomes in patients with unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM). METHODS: Twenty-six consecutive patients (16 men and 10 women; mean age: 52 years (range: 32-69)) with C1 LM USSF were included in this study. Sixteen were TAL injury group (nine of type I injuries and seven of type II injuries according to Dickman's classification) and ten were TAL intact group. All cases were conservatively treated with a rigid brace for TAL intact or by halo-vest stabilization for TAL injury for three months. The mean follow-up was 16 months (range, 12-47 months). The results were compared with radiological assessment of fracture healing, LM displacement and Neck visual analog scale. RESULTS: At the last follow-up, for TAL intact group, total LM displacement (LMD), unilateral LMD of fracture side, atlanto-dental interval, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were maintained compared to initial presentation. However, for TAL injury group, all radiological parameters were worsened. The worsening of radiological parameters was more severe in type I injury than type II injury except for total LMD and unilateral LMD. Neck visual analog scale significantly decreased and patient's satisfaction was higher in TAL intact group compared to TAL injury group. CONCLUSION: Conservative treatment for USSF of C1 LM with TAL injury failed to achieve healing of the fracture, which resulted in lateral displacement of C1 LM. This caused coronal and sagittal malalignment of occipitocervical junction, resulting in unsatisfactory clinical outcomes. Our results suggest that early surgical stabilization should be considered in USSF of C1 LM with TAL injury, especially type I injury. However, conservative treatment may be sufficient for a USSF of the C1 LM with TAL intact. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Another diagnostic tool in thoracolumbar posterior ligament complex injury: interspinous distance ratio.

PURPOSE: The increased interspinous distance ratio (ISDR) at the fracture site in plain X-ray is useful as an indicator of injury of the posterior ligament complex in thoracolumbar fractures. METHODS: 154 patients of thoracolumbar junctional fracture (T12, L1, L2) were subjects for this study. The sensitivity, specificity, accuracy of MRI was measured by comparing the surgery findings for the two analysis groups: one in which indeterminate cases were included in the intact group and another in which the indeterminate cases were included in the ruptured group. Sensitivity, specificity, accuracy of ISDR (measured in lateral decubitus X-ray) were measured after dividing patients into 3 groups (110, 120, 130 % increased). RESULTS: MRI's sensitivity, specificity and accuracy were 70.8, 100, and 80.5 %, respectively, when the indeterminate was assumed to have intact PLC. After assuming the indeterminate to have ruptured PLC, sensitivity, specificity and accuracy were 99.1, 52.4, and 85.7 %, respectively. In 53 cases with indeterminate MRI reading, sensitivity, specificity and accuracy were 81.2, 76.2, and 79.2 % %, respectively. CONCLUSION: In this study, in cases where it was difficult to make a diagnosis of the injury in the posterior ligament complex, based on the interspinous distance ratio (ISDR) of 120 % measured in plain X-ray in a lateral decubitus position, the sensitivity was 81.3 %, the specificity was 76.2 %, and the accuracy was 79.2 %. Therefore, measuring the ISDR will be helpful in determining whether surgical treatment is required in patients with thoracolumbar injury.

Comparison of blood loss according to use of aspirin in lumbar fusion patients.

OBJECTIVE: To investigate and compare blood losses intra and postoperatively between lumbar fusion patients with and without antiplatelet use. METHODS: A total of 106 patients who had undergone at least 2 or more segments of lumbar fusion surgery were selected for the study. They were divided into three groups. Group 1 was not on medication before the surgery. Groups 2 and 3 had taken aspirin prior to the surgery. Group 2 discontinued the medication 1 week before the operation, but group 3 continued the use. In addition, non-steroid anti-inflammatory drug (NSAIDs) use in all patients was questioned. Amount of blood losses and platelet function were evaluated. RESULTS: When usage of NSAID was not controlled, intraoperative, postoperative, and total blood losses were found to have no statistical significance among the groups. However, when NSAID usage was taken into account, there were significantly higher blood losses in groups 2 and 3 compared with group 1. The use of NSAID resulted in significantly higher blood loss in group 1, but not in groups 2 or 3. The platelet function test results disclosed statistical differences between groups 1 and 2 and groups 1 and 3. CONCLUSION: Aspirin significantly increases the risk of bleeding in patients undergoing lumbar fusion at two or more levels. This risk is present even in patients who discontinued aspirin 1 week prior to surgery. In patients with high risk of complications resulting from aspirin discontinuation, the use should be allowed in lumbar fusion surgery. However, strong attention must be paid to avoid excessive bleeding. Because NSAID use also increases surgical blood loss, proper interval from discontinuation to surgery must be granted to minimize the risk.

Validation in the cross-cultural adaptation of the Korean version of the Oswestry Disability Index.

Disability questionnaires are used for clinical assessment, outcome measurement, and research methodology. Any disability measurement must be adapted culturally for comparability of data, when the patients, who are measured, use different languages. This study aimed to conduct cross-cultural adaptation in translating the original (English) version of the Oswestry Disability Index (ODI) into Korean, and then to assess the reliability of the Korean versions of the Oswestry Disability Index (KODI). We used methodology to obtain semantic, idiomatic, experimental, and conceptual equivalences for the process of cross-cultural adaptation. The KODI were tested in 116 patients with chronic low back pain. The internal consistency and reliability for the KODI reached 0.9168 (Cronbach's alpha). The test-retest reliability was assessed with 32 patients (who were not included in the assessment of Cronbach's alpha) over a time interval of 4 days. Test-retest correlation reliability was 0.9332. The entire process and the results of this study were reported to the developer (Dr. Fairbank JC), who appraised the KODI. There is little evidence of differential item functioning in KODI. The results suggest that the KODI is internally consistent and reliable. Therefore, the KODI can be recommended as a low back pain assessment tool in Korea.